Elevate Care Palos Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Palos Heights, Illinois.
- Location
- 12550 South Ridgeland Avenue, Palos Heights, Illinois 60463
- CMS Provider Number
- 145779
- Inspections on file
- 23
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Elevate Care Palos Heights during CMS and state inspections, most recent first.
A staff member failed to obtain permission from an alert and oriented resident before checking for incontinence and inappropriately touched the resident's vaginal area, causing the resident to feel violated and emotionally harmed. The staff member admitted to not getting explicit permission and used an improper method to check the brief. Facility policy and staff interviews confirmed that permission and proper technique are required, and the incident was reported as abuse.
A resident and their family alleged abuse by staff, which was reported to the administrator by an LPN. However, the administrator did not notify the state department within the required two-hour window, as confirmed by the VP of Operations. The DON later reported the allegation, but the delay violated the facility's abuse reporting policy.
The facility did not maintain a safe kitchen environment, with broken floor tiles present throughout the kitchen for several years and a non-functioning exhaust fan above the stove, resulting in excessive heat. Staff confirmed these issues had persisted over time, affecting food preparation for all residents.
A resident with moderate cognitive impairment had personal funds deposited with the facility, but after the resident's death, the family reported not receiving the money. The administrator and DON gave conflicting accounts of the release of the funds, and there was no documentation or signed receipt to confirm the transaction, indicating a failure to properly record and manage resident funds.
Multiple residents, including those with cognitive impairments and dependence on toileting hygiene, were found in unsanitary conditions with soiled briefs and linens, and strong urine and feces odors were present in hallways and common areas. Housekeeping staff were unaware of the odor sources, and the facility did not meet its policy for maintaining a clean, odor-free, and comfortable environment.
Three female residents with cognitive impairment who were dependent on staff for toileting hygiene were not provided timely incontinent care, resulting in them being found with urine and feces-soaked briefs, pads, and linens, and strong odors in their rooms. Care plans and facility policy required regular checks and perineal care after each episode, but these were not followed, as confirmed by a CNA and the DON.
The facility failed to ensure call lights were within reach for two residents, one with cerebral palsy and contractures, and another with multiple sclerosis. The first resident's custom call light was not accessible, and the second resident's call light was found on the floor. Staff confirmed that call lights should have been within reach to accommodate the residents' needs.
The facility failed to follow infection control practices for respiratory equipment, affecting two residents. A resident's nebulizer mask was left uncovered, and another's CPAP mask was not stored properly. Staff acknowledged the equipment should be stored in labeled plastic bags, as per facility policy.
A resident with a right arm precaution bracelet and signage had blood drawn from the wrong arm by a third-party phlebotomist, leading to swelling. The facility's staff were unaware of the lab visit, and the precaution was documented through various means. The phlebotomist did not adhere to communication and site selection guidelines.
A facility failed to protect a resident from mental abuse by a staff member, leading to the resident feeling unsafe and untrusting. The resident reported an incident where a dietary aide refused food and used derogatory language. Despite the aide's termination, the administrator rehired him as a CNA, allowing him to provide direct care, which continued to distress the resident.
A resident reported that a dietary aide repeatedly entered her room and took her personal beverages without permission, despite her requests for the aide to stop. The resident, who is cognitively intact and has Conversion Disorder and Generalized Anxiety Disorder, expressed discomfort with the aide's actions, which violated the facility's policy against misappropriation of resident property.
The facility failed to report an allegation of misappropriation of property and did not timely report an allegation of physical abuse to IDPH. A resident reported a dietary aide took a beverage, which was not recognized as misappropriation. Another resident reported rough care by a CNA, but the administrator delayed reporting due to not checking emails over the weekend. The facility's policy requires immediate reporting, which was not followed.
A facility failed to investigate an allegation of misappropriation of property when a resident reported that a dietary aide was taking their personal drinks. The administrator did not interview other residents or staff and could not provide documentation of an investigation, contrary to the facility's abuse policy.
The facility failed to maintain accurate records of controlled substances, affecting 15 residents. The Director of Nursing and Nursing Supervisor admitted to shredding forms used for recording the use of controlled substances, which were not uploaded into the electronic health record. The facility's policy required detailed drug disposition records, but these were not maintained, leading to discrepancies. The affected residents included those discharged, still residing, or expired, with medications like hydrocodone/acetaminophen and alprazolam involved.
A resident suffered a fracture to the left distal tibia after being improperly transferred using a mechanical lift by two CNAs, one of whom was new and in training. The incident was not immediately reported or documented, and the facility's investigation revealed a lack of adherence to safety protocols and insufficient staff training on mechanical lift use.
Failure to Obtain Permission and Inappropriate Touching During Incontinence Check
Penalty
Summary
A staff member failed to obtain permission from an alert and oriented resident before checking for incontinence and inappropriately touched the resident in the vaginal area. The resident, who had multiple medical diagnoses including a femur fracture, congestive heart failure, diabetes, atrial fibrillation, chronic kidney disease, COPD, anxiety disorder, major depression, obesity, and GERD, reported feeling angry, violated, and emotionally harmed by the incident. The resident described waking up to the staff member's hand between her legs under her brief, touching her vaginal area, and stated that she pushed the staff member's hand away and told him to leave. The resident subsequently reported the incident to her family, who contacted the police, and expressed a desire to pursue the matter criminally. The staff member involved stated that he announced himself and informed the resident he was there to check if she was dry, but omitted obtaining explicit permission before touching the resident. He reported patting the resident's brief to check for wetness and did not provide further incontinence care during that shift. The staff member acknowledged that the resident was alert and oriented and typically requested assistance when needed. Other staff interviews confirmed that facility practice requires staff to announce themselves, inform residents of intended care, and obtain permission before touching alert and oriented residents. It was also noted that patting or massaging a brief is not an accepted practice for checking incontinence. Facility policies reviewed indicated that residents are to be treated with respect and dignity, and that staff must explain procedures and obtain permission before providing care, especially for alert and oriented residents. The policies also prohibit abuse, neglect, and mistreatment, and require the prevention of such occurrences. The resident's care plan emphasized the need for person-centered care and maintaining a supportive environment, but the baseline care plan did not include a toileting assessment. The failure to follow these protocols resulted in the resident experiencing emotional distress and reporting the incident as abuse.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to follow its policy regarding the timely reporting of an abuse allegation for one of three residents reviewed. On 9/19/25 at approximately 10:30pm, a resident and their family alleged abuse by staff, and an LPN reported that the administrator was made aware of the allegation that night. However, the administrator did not report the allegation to the state department within the required two-hour timeframe. The Vice President of Operations confirmed that the report was not made within two hours as required by facility policy. The Director of Nursing stated that the allegation of sexual abuse was reported to the state department on 9/20/25 at 1:43pm. Review of the facility's abuse prevention and reporting policy indicated that any allegation of abuse or incident resulting in serious bodily injury must be reported to the department of public health immediately, but not more than two hours after the allegation is received. The facility's failure to report the abuse allegation within this timeframe constitutes a deficiency in following established abuse reporting protocols.
Failure to Maintain Safe and Functional Kitchen Environment
Penalty
Summary
The facility failed to maintain a safe and functional kitchen environment, as evidenced by broken ceramic floor tiles throughout the kitchen and a non-functioning exhaust fan above the stove. Observations confirmed that the kitchen floor had missing and uneven tiles, a condition that had persisted for at least five years according to staff interviews. The exhaust fan was not operational, resulting in unusually high temperatures around the stove area. Staff members, including dietary aides and cooks, reported that these issues had been ongoing, with the broken tiles present since their employment began and the exhaust fan not working on consecutive days. The dietary manager and maintenance director acknowledged the problems, stating that maintenance was aware of the exhaust fan failure and that efforts were underway to replace the broken tiles. The facility's environmental services policy requires the environment to be maintained in a manner that promotes health and safety for residents, personnel, and the public. At the time of the deficiency, 92 residents were consuming food prepared in the affected kitchen, but no specific medical history or conditions of the residents were mentioned in relation to the deficiency.
Failure to Properly Record and Release Resident Funds
Penalty
Summary
The facility failed to establish and maintain a proper system for recording and releasing resident funds in accordance with generally accepted accounting principles. Specifically, for one resident with moderate cognitive impairment, there was a lack of documentation and proof regarding the release of $200 in cash and a $400 cashier's check that were deposited with the facility. After the resident's death, the family was informed that the funds had already been released, but the family reported never receiving the money. The administrator stated that the resident's wife collected the funds prior to the resident's death, but there was no documentation or signed receipt to confirm this transaction. Interviews with staff revealed inconsistencies in the account of how and when the funds were released. The DON recalled that the administrator gave the money to the wife and daughter but might have forgotten to record it. The administrator described instructing another staff member to retrieve and hand over the funds, but admitted that the normal process of obtaining a signed receipt was not followed and no proof of the transaction was available. A review of clinical records and documentation for the relevant period showed no evidence that the funds were released to the family.
Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for several residents, as evidenced by persistent foul odors and unsanitary conditions in resident rooms, hallways, and common shower areas. Observations revealed strong urine and feces smells in the 300 hallways and the common shower room. Housekeeping staff were unaware of the source of the odors and had not yet addressed the issue at the time of observation. Multiple residents were found in their beds with intense urine and feces odors, and incontinent briefs and linens were observed to be soiled and discolored with urine and feces. These conditions were directly observed by surveyors and confirmed by staff interviews. Several residents with varying degrees of cognitive impairment and dependence on toileting hygiene were affected. One resident with mild cognitive impairment was found with urine and feces-soaked briefs and soiled linens, while another with severe cognitive impairment was similarly found with feces-soaked briefs and linens. A third resident with moderate cognitive impairment was observed with soiled briefs and linens, and the hallway near her room also had a strong odor. Additionally, a resident with intact cognition reported that her room and the hallways were smelly, particularly after a roommate change. The facility's own housekeeping policy requires a clean, odor-free, and comfortable environment, but this standard was not met during the survey.
Failure to Provide Timely Incontinent Care to Dependent Residents
Penalty
Summary
Three female residents with varying degrees of cognitive impairment, all dependent on staff for toileting hygiene, were not provided timely incontinent care as required by their care plans and facility policy. Observations revealed that these residents were found in their beds with intense urine and feces odors, and their briefs, pads, and linens were soaked and discolored from urine and feces. The care plans for these residents specified that perineal care should be provided after each incontinent episode and that residents should be checked at regular intervals, including upon rising, before and after meals, at bedtime, and as needed. A Certified Nursing Assistant (CNA) reported that she began her shift at 6:00 AM but had not had the opportunity to change some of her assigned residents, including the three affected individuals, by late morning. The Director of Nursing confirmed that incontinent care should be provided at least every two hours and that the environment should be odor-free. The facility's incontinence policy also requires periodic checks and perineal care after each episode, which was not followed in these cases.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating their needs. On January 21, 2025, a resident with cerebral palsy and contractures was observed in bed without their custom call light within reach. A Certified Nursing Assistant (CNA) confirmed the absence of the call light, which was necessary for the resident to request assistance due to their condition. The Director of Nursing (DON) acknowledged that the call light should have been accessible. Additionally, another resident with multiple sclerosis was found asking for their call light, which was on the floor and out of reach. A nurse subsequently attached the call light to the bed, ensuring it was accessible. The DON confirmed that the call light should always be within reach for this resident, who was at risk for falls due to deconditioning.
Infection Control Deficiency in Respiratory Equipment Handling
Penalty
Summary
The facility failed to ensure proper infection control practices in handling respiratory equipment, affecting two residents. One resident's nebulizer mask was observed uncovered on a dresser, with tubing that was neither dated nor labeled. A Licensed Practical Nurse acknowledged that the nebulizer mask should be covered in a plastic bag with the tubing labeled and dated, as per the facility's policy. The Director of Nursing confirmed that the nebulizer masks should be stored in a plastic bag with the resident's name and date for infection control purposes. Another resident's CPAP machine was found on a nightstand with the mask and cannula not stored in a plastic or zip lock bag when not in use. The Licensed Practical Nurse and the Director of Nursing both stated that the CPAP mask and cannula should be stored in a plastic or zip lock bag when not in use, in accordance with the facility's policy on oxygen and respiratory equipment. The resident had a diagnosis of sleep apnea and was required to wear the CPAP at bedtime, as documented in their care plan.
Improper Blood Draw from Resident with Limb Precautions
Penalty
Summary
The facility failed to ensure a proper blood draw from a resident with limb precautions, affecting one resident. The incident occurred when a third-party phlebotomist drew blood from the resident's right arm, despite the presence of a precaution bracelet and a sign at the head of the bed indicating no blood draws or blood pressures should be taken from that arm. The Director of Nursing and the primary nurse were reportedly unaware of the lab visit on the day of the incident. The resident's arm was swollen as a result of the incorrect blood draw. Interviews with staff revealed that the precaution was well-documented and communicated through various means, including a bracelet, signage, physician orders, and computer charting. The phlebotomist, who was covering for the usual staff, claimed not to have seen the precautionary indicators. The facility's phlebotomy guidelines emphasize the importance of communication and correct site selection, which were not adhered to in this instance.
Failure to Prevent Mental Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from mental abuse by a staff member, resulting in the resident feeling unsafe and untrusting. The resident, who is cognitively intact and uses a wheelchair, reported an incident where a dietary aide refused to provide food and called her a derogatory name. The resident had previously allowed the aide to consume her personal beverages but stopped, which she believed led to the aide's negative behavior. The resident reported the incident to the facility administrator and dietary manager, leading to a meeting with her family and the termination of the aide. Despite the termination, the administrator later rehired the aide as a CNA and brought him to the resident's room to apologize. However, the apology was not specific to the incident, and the resident continued to feel unsafe as the aide was now providing direct care and entering her room. The resident expressed feeling guarded and concerned about the aide's behavior, fearing for her safety and the safety of other residents who might not be able to defend themselves. The facility's abuse prevention policy, which the aide had acknowledged, defines abuse as actions causing mental anguish. The policy emphasizes the resident's right to be free from abuse, including mental abuse. The facility's failure to limit the aide's access to the resident after the incident contributed to the resident's ongoing distress and lack of trust in the facility's ability to ensure her safety.
Failure to Protect Resident's Belongings from Misappropriation
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her property, specifically her beverages, by a staff member. The resident, a cognitively intact female with Conversion Disorder and Generalized Anxiety Disorder, reported that a dietary aide, with whom she was initially friendly, began entering her room uninvited and taking her personal soda from her refrigerator. This behavior continued even after the resident expressed discomfort and asked the aide to stop entering her room, especially after she got a roommate. The incident was reported to the facility administrator, who documented the resident's concern that the dietary aide was taking and drinking her drinks. The facility's abuse prevention and reporting policy, which prohibits misappropriation of resident property, was acknowledged by the dietary aide prior to the incident. Despite this, the aide's actions led to a deficiency in protecting the resident's belongings, as the aide continued to enter the resident's room and take her beverages without permission.
Failure to Timely Report Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to report an allegation of misappropriation of property for a resident and did not timely report an allegation of physical abuse for another resident to the Illinois Department of Public Health (IDPH). These deficiencies were identified during a review of three residents for abuse. One resident, a cognitively intact female with conversion disorder and generalized anxiety disorder, reported that a dietary aide took a beverage from her room. The facility administrator did not recognize this as misappropriation of property and failed to report it to IDPH until the following day. Another resident, a female with multiple fractures and autism, reported rough care by a CNA to her family member, who then emailed the facility administrator. The administrator did not check the email over the weekend, resulting in a delay in reporting the incident to IDPH. The CNA continued to provide care to the resident after the allegation was reported. The facility's policy requires immediate reporting of such incidents, but this was not adhered to in these cases.
Failure to Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of misappropriation of property involving a resident. The incident involved a resident who reported that a dietary aide was taking and drinking their personal drinks. The administrator acknowledged being informed of the concern but did not interview other residents or staff about the allegation and was unable to provide any written documentation related to an investigation. The facility's abuse policy requires interviews with residents and employees who have interacted with the accused to determine if there have been any prior incidents of misappropriation, but this procedure was not followed in this case.
Failure to Maintain Controlled Substance Records
Penalty
Summary
The facility failed to maintain a proper record of controlled substances, affecting 15 residents who were reviewed for the disposition of controlled drugs. During the survey, it was found that the facility did not account for each dose of narcotic medications given and disposed of, as required by their policy. The Director of Nursing and Nursing Supervisor admitted that they were responsible for disposing of controlled medications but were unable to provide documentation for each dose used or disposed of. The forms used for recording the use of controlled substances were shredded and not uploaded into the electronic health record, which was against the facility's policy. The facility's policy required that the drug disposition record include specific details such as the resident's name, date of drug destruction, name and strength of the drug, prescription number, quantity destroyed, method of destruction, and signatures of witnesses. However, the forms provided by the Director of Nursing did not include the method of destruction, and the forms were not part of the resident's individual record. The facility did not have a policy stating that these forms needed to be preserved in the resident records, leading to discrepancies in the accounting of controlled substances. The residents affected by this deficiency included those who were discharged, still residing in the facility, or had expired. The medications involved were various controlled substances such as hydrocodone/acetaminophen, pregabalin, alprazolam, oxycodone/acetaminophen, and others. The facility's failure to maintain accurate records of these medications was confirmed by the pharmacist and medical director, who stated that the nurses were expected to document the count of each medication using the count sheet that accompanied the medication dispensed. This documentation should have been part of the resident's medical record for future reference and review.
Improper Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in an injury. During the transfer of a resident from a wheelchair to a bed, the resident's left foot bumped the footboard, leading to a fracture of the left distal tibia. This incident involved two CNAs, one of whom was new and undergoing orientation. The CNAs were unable to explain how the mechanical lift pad shifted during the transfer, which contributed to the resident's injury. The resident involved in the incident was alert and oriented with a BIMS score indicating moderate impairment. The resident had a history of falling, difficulty in walking, and muscle weakness, which necessitated the use of a full-body lift for transfers. Despite the resident's condition, the CNAs did not report any immediate signs of pain or injury following the incident, and the LPN on duty did not document the occurrence in the resident's progress notes. The facility's policy requires that mechanical lifts be operated by two people to ensure resident safety. However, the CNAs involved did not follow proper procedures, as evidenced by the shifting of the lift pad. The Director of Nursing was not informed of the incident until days later when the resident began to show signs of pain. The facility's investigation revealed a lack of documentation and communication regarding the incident, and there was no evidence of prior training for staff on the use of mechanical lifts.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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